Policy responses for Estonia - HSRM


Policy responses for Estonia

1.5 Testing

On April 16, the Government decided to support the proposal of the University of Tartu to carry out two studies in order to determine the spread of the coronavirus in the population and to inform combating COVID-19.

The first study will be carried out through interviews and testing based on random samples. Every week, 2,000 people will be tested, regardless if they have symptoms or not, to assess the spread of the infection across the country in different counties and population groups. The cost of the research project is EUR 1.8 million. The results of the monitoring project will be reported to the Governmental Committee every week.

As of May 18, the results of the monitoring study (conducted by the University of Tartu) indicate that the spread of the novel coronavirus in Estonia remains low. Researchers also briefed the Government Emergency Committee on the results. Over the course of two weeks, a total of 6,024 randomly selected adult residents were interviewed and 4,728 were tested for the novel coronavirus. Of these, 12 tested positive for the virus, seven of whom had already been diagnosed prior to the survey, and six of which had already recovered by the time of the survey.
Source: https://www.ut.ee/en/research/study-prevalence-coronavirus-estonia

The second study will take place in Saaremaa (epicenter of Estonian outbreak) and Õismäe (one city district in Tallinn) as the pilot project for sero-epidemiological research at a cost of EUR 300,000. The purpose of the study is to determine how many people have been exposed to the coronavirus. The Estonian Health Insurance Fund will select a random sample of 1,080 people from each community. The recruitment and analysis of volunteer data will be carried out by family doctors. A blood sample will be taken from the vein to determine the presence of antibodies, which shows whether a person has been infected with COVID-19.  The study will take place from May 1 to July 31. 

Source: https://www.valitsus.ee/en/news/members-government-supported-university-tartu-research-better-mapping-covid-19-spread

At the end of August, the results of the population-based study on coronavirus antibodies led by the University of Tartu indicate that the prevalence of the virus notably exceeded the national statistics based on nasal swab testing: by a factor of 10 in Tallinn and 3.5 in Saaremaa. Only 20% of people who had coronavirus antibodies in their blood had shown a symptom of the disease. The study is financed by the Government. In addition to monitoring the prevalence of COVID-19 through the study on antibodies, the University of Tartu is about to start two more studies in which researchers will collect data on the spread and nature of the virus. In the coming weeks, researchers will launch a study in which the genetic sequences of the COVID-19-causing virus spreading in Estonia will be examined to determine the source of unknown infections. Also, a monitoring system of COVID-19 based on wastewater analysis will be started to help detect broader virus spread at the earliest possible stage.

Source: https://meditsiiniteadused.ut.ee/en/news/coronavirus-ten-times-more-prevalent-previously-thought 

The ongoing study conducted by University of Tartu suggests that 21% of the population has antibodies in April 2021. The previous results from one month before indicated 11% of the population had antibodies. Of the 21% of the population with antibodies, 10% have them because they were infected previously and 11% because they were vaccinated. As of April 2021, every 40th adult is currently infected and nearly half are without symptoms. Of the people with COVID-19, 40% will not be identified through testing as they do not have symptoms or have very mild symptoms and do not go to testing but they can still infect others.

The percentage of people who avoid physical contact, small gatherings, keep safe distance from others and avoid travelling (in the country and out) has increased. Also the number of people who continue to live as usual after knowing that they are contacts of a COVID-19 case has decreased. Still, nearly 20% of respondents still continue to live as normal and 30% change very little of their behavior.

On 14 May, Finland and Estonia will begin to relax border restrictions between the two countries. To help limit the potential spread of the coronavirus, between 14-19 May, testing will be offered on a voluntary basis for individuals travelling to Estonia by ship (for more details, please see Section 6 – Measures in other sectors).

Coronavirus testing will continue from June in 11 mobile locations around Estonia. In addition, private sector healthcare firms and buses will take testing samples, which can be accessed on foot or by bicycle.

From 1 September, in the event of a negative coronavirus test result shown immediately upon arrival in the country, it is possible to go to work after coming from at-risk countries if this is absolutely necessary. Until the result of the test is known, the person must remain in complete self-isolation. In case of a negative test result, the person must stay in self-isolation for the first seven days, i.e. they can go to work and, for example, a shop, but must avoid unnecessary contacts. A second test must be performed no earlier than 7 days after the result of the first test, and if it is negative, the person can resume normal life. This means that a person will not be subjected to 14-day self-isolation after two negative tests, which applies to all those coming from high-risk countries.

This does not apply to people who have come to work and study from a third country on the EU’s single list. The tests take place at Tallinn Airport and the two main passenger ferry terminals. Testing is not mandatory, but not taking a test means individuals arriving from high-risk countries must isolate at their place of stay for 14 days. Testing is free of charge for Estonian citizens.

The 14-day restriction on travel-related freedom of movement still does not apply to existing exemptions, such as for foreign diplomats, vital service providers, staff involved in passenger and freight transport, and so on. Foreigners whose arrival in Estonia is related to maintenance of equipment of a company operating here or to other essential work necessary to ensure the operation of the company must now take the test to work when crossing the state border.

The Health Board has concluded a potential €100-million contract for coronavirus testing through to year-end. The procurement was awarded to private sector firms Medicum and Synlab, who had been providing testing services for the state through much of the pandemic in any case. OÜ Medicum Eriarstiabi and Synlab Eesti made a joint bid, which proved successful after the State Shared Services Center (RTK) awarded the contract, whose terms could reach €100 million. The selected provider must be able to perform coronavirus testing across Estonia, establish and service sampling sites, provide a mobile sampling brigade service for testing at a patient's home and, if necessary, form a special brigade for testing in nursing homes and other institutions. The contract also includes the transport and analysis of samples and the communication of results to patients. Under the terms of the agreement, test results must be available within 48 hours of taking a test and, if the result is positive, the individual must be contacted by the testing center. So far two new testing places have been opened (for a total of 21 with nearly 500 employees) and one additional home testing unit has been established (for a total of 10 brigades that test people at home).

From December 2020, hospitals that do not have the lab capacity for PCR testing can use antigen tests. In addition, antigen tests are also used in nursing homes to quickly divide the clients into positive and negative groups when an outbreak arises in the nursing home. When healthcare workers are tested using antigen tests, all cases that have a positive result will be counted as positive (but not counted as positive case in official data because for this a PCR is needed) and negative results will be confirmed with PCR tests. When the availability of antigen tests improves it is planned to use them also in other indoor locations like jails and schools who have healthcare workers available on site.

From the 16th of February 2021, an Estonian private lab started to use throat liquid to test COVID-19 among children. They will use the throat liquid sample instead of nasal swab and do the PCR test with the liquid, however the Health Board will not use it as an official method for testing as it needs more validation.

The project KoroGeno-Est-2 started in early January 2021 and  aims to determine 350 whole-genome sequences of SARS-CoV-2. The project team comprises researchers from the Institute of Clinical Medicine, Institute of Biomedicine and Translational Medicine and Institute of Technology of the University of Tartu and specialists from SYNLAB Eesti OÜ and the Health Board. During the KoroGeno-Est-1 more than 300 whole-genome sequences of SARS-CoV-2 were determined (1.09.2020− 31.12.2020).

In January 2021 the Government allocated additional funds to the whole-genome sequencing of COVID-19 cases (400,000 EUR). The Health Board has a contract with the University of Tartu that allows them to sequence 400 new positive cases per week. Most of these cases come from abroad and when the source of the infection is not known they will be sent to whole-genome sequencing. In addition, the Health Board sends 200 new cases for testing to ECDC. The aim is to soon secure the sequencing of 5-10% of all new cases.

Source: https://www.hm.ee/et/uudised/riik-suunab-koroonaviiruse-tuvede-uurimiseks-taiendavalt-400-000-eurot

As of the end of March, the rapid tests for professional use became available in pharmacies in Estonia.

The two types of rapid tests currently on sale are saliva-based or nasopharyngeal (cost €25 and €14 respectively). Both are only available for purchase and use by professionals.

Source: https://news.err.ee/1608151636/rapid-tests-can-now-be-bought-in-estonian-pharmacies 

People are tested when they show symptoms of COVID-19. The family doctor decides whether an individual needs to be tested and refers the patient for testing. Testing priority is given to older people and the chronically ill, regardless of their age, which means that in justified cases people of all ages are tested if they have symptoms. All hospitalised patients who have coronavirus symptoms are also tested.

All other suspected cases are tested based on the GP digital referral, taking into account the case definition and the medical justification. A special digital referral system was developed mid-March to simplify the referral process. Patients without a GP contact should first call the family physician advisory line 1220. This call line provides contact information for regional on-call PHC centres where patients can receive a referral for testing. Health care professionals and front-line providers of vital services can be sent to testing without a GP referral.

Starting from 28 March, Estonia will open out-of-hours PHC centres to ensure access to testing referrals during the weekends. The family physician advisory line 1220 will forward suspected patients to these PHC centres, which are open from 8:00 am to 6:00 pm.
Testing is organized through testing centres (since 19 March two centres, in Tallinn and Tartu) who receive referrals and contact patients to agree on a testing place and time.

Testing for people with GP referrals is organised in cooperation with private providers. Drive-in testing points have been set up in 8 regional centres, and are open from 8am to 9pm. Mobile teams pick up samples at home for people not able to drive to the testing point.
Random sampling is also used to test medical workers without symptoms of illness, care home workers, social workers, police and border guard officers, rescue service workers and other front-line professionals, who due to their work may pose a danger to risk groups.

Testing capacity is about 1000 tests per day (as of 27 March). Testing is carried out in the Health Board reference laboratory, 4 hospital laboratories and a private laboratory Synlab. 
Patients receive their test results digitally over the Patient Portal. If the tests have been done by the private laboratory Synlab, they will also notify patients with an SMS.

Sources: https://www.terviseamet.ee/et/koroonaviirus/, https://www.kriis.ee/et

As of 1 April, the Health Board approved 9 hospitals to use their GeneXpert equipment for rapid tests Cepheid Xpert Xpress for SARS-CoV-2. Rapid testing will be mainly used to improve the patient flow in emergency departments and to understand the prevalence of immunity in the population.

The Health Board adopted a new strategy for testing in nursing homes. Recently, people living in nursing homes have confirmed COVID-19 cases, so the Heath Board has started to test all the personnel and residents when symptoms appear, which may require repeated testing.

Starting from 1st of April, the results of laboratory tests of COVID-19, which are entered in the national health information system, will be available in real-time on the Health Board's website.

The Health Board has updated the testing strategy. Starting from April 8th, family physicians are able to refer all people with COVID-19 symptoms to testing, regardless of their age and associated diseases. The testing arrangements have not changed; people must first contact the family physician, who will decide whether testing is needed and then refer the patient, if necessary. The doctor will assess each case individually.

The purpose of the change in the testing strategy is to obtain a more accurate epidemiological overview of the spread of the coronavirus in Estonia in order to assess more precisely the current interventions and plan further actions.

As of 16 April, five additional testing points will be opened in five towns across the country during coming days in order to scale up the testing capacity across the country. The testing is organised by seven private medical companies and three public hospitals.

In April, the Health Board conducted a closed procurement procedure to outsource testing capacity to two private sector providers, which organize testing in 14 different locations across the country. The total amount of the contract is EUR 1,734,384 and the contract is effective until May 14.

The State Shared Service Centre conducted earlier procurements without prior publication of a contract notice through the negotiation procedure by in a total amount of EUR 2.1 million. These contracts terminated on April 16.

Private sector testing capacity plays crucial role at this stage. As of April 16, Estonia has conducted 33,967 tests of which 24,000 were done in private sector, 3,060 in the Health Board lab and remaining in hospital laboratories.

Source: https://forte.delfi.ee/news/varia/synlab-ja-medicum-said-terviseametilt-jarjekordse-miljonilepingu?id=89637255 

For the first time in history, a drone was used for conveying a coronavirus sample from Estonia's second-largest island, Hiiumaa, for testing in Tallinn. The pilot initiative was a joint effort by the North Estonia Medical Center and technology company Threod Systems. The lab service in the mainland is already well established and the samples are able to reach labs within one-and-a-half hours. However, it is more challenging to ensure timely access to various islands off the coast of Estonia. The Threod Systems drones include drones with ranges of 100 kilometers which can carry a maximum payload of more than one kilogram, which makes them suited for operation between the mainland and the small islands.

Source: https://news.err.ee/1081652/first-ever-drone-flight-carrying-coronavirus-patient-sample-in-estonia